Learning curve and postoperative outcomes of minimally invasive esophagectomy

Learning curve in retroperitoneal sarcoma surgery

INTRODUCTION

Retroperitoneal sarcoma (RPS) surgery poses unique challenges. This retrospective study aimed to analyze the learning curve (LC) in RPS surgery, assessing the relationship between surgical experience and outcomes.

MATERIALS AND METHODS

Cumulative sum (CUSUM) analysis was used to analyze 62 RPS surgeries performed by a single surgeon between 2016 and 2022 at our center.

RESULTS

The number of cases where the surgeon acted as first operator increased from 3 in 2016 to 13 in 2022. The surgeon operated with his mentor in 66.7 % of cases in 2016, whereas in 7.7 % of cases in 2022. LC consisted of 3 phases. Phase 1 (16 cases), with a negative slope, represented shorter operative time (OT) and fewer number of resected organs (RO). Phase 2 (30 cases) was the plateau phase. Phase 3 (16 cases), with a positive slope, indicated longer OT and more RO. Statistically significant differences were observed in terms of size (p = 0.003), presentation (p = 0.048), number of resected organs (p = 0.046), pattern of resection (p = 0.033), OT (p = 0.006), and length of stay (p = 0.026) between the three phases.

CONCLUSION

This study focused on the critical role of LC in RPS surgery, emphasizing its influence on outcomes. We identified three phases, highlighting the surgeon's evolution. This offers a framework for educating sarcoma surgeons and ensuring exposure to increasing surgical complexity. In discussions on sarcoma referral centers and the correlation between case volume and outcomes, this study underlines the importance of evaluating LC to distinguish surgeons qualified to manage sarcoma cases within a referral center.

Triphasic Learning Curve of Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an effective but costly procedure for select patients with peritoneal malignancies. The impact of progression along a learning curve on the cost of these procedures is unknown.

PATIENTS AND METHODS

We performed a retrospective cohort study of patients undergoing CRS-HIPEC from 2016 to 2022 at a single quaternary center. Our study cohort was temporally divided into four equally sized volume quartiles (A, B, C, and D). We utilized cumulative sum plots and split-group analysis to characterize the institutional learning curve based on cost, operative time, length of stay, and morbidity. Multivariable linear regression was performed to estimate costs after adjusting for covariates. Bivariate analysis was performed using a Kruskal-Wallis test to compare continuous variables and a χ2 test to compare categorical variables.

RESULTS

Of 201 patients, the median age [interquartile range (IQR)] was 57 (47-65) years, 113 (56%) patients were female, 143 (71%) were white, and 107 (53%) had private insurance. Median operating room charge [US$42,639 (US$32,477-54,872), p < 0.001] varied between volume quartiles, peaking in quartile C. Stabilization was achieved for 86 cases for operating room cost, 88 cases for routine cost, 96 cases for length of stay, 103 cases for operative time, 120 cases for intensive care unit length of stay, and 150 cases for overall and serious morbidity. The actual operating room and routine costs were similar to predicted costs at the end of the study period.

CONCLUSIONS

The CRS-HIPEC learning curve is triphasic, with cost stability achieved relatively early compared with other markers of surgical proficiency.

Evaluating robotic assistance on the learning curve and efficiency of mandibular angle ostectomy: an animal model study

Introduction

This study evaluated the efficacy and learning curve of a maxillofacial surgical robotic system (MSRS) guided by electromagnetic navigation for mandibular angle ostectomy (MAO), compared to traditional surgical methods.

Methods

The study utilized a controlled experiment involving thirty rabbits, paired divided into experimental and control groups. The experimental group underwent MAO using the MSRS, while the control group was treated with conventional surgical techniques. The surgeons performing the procedures were inexperienced in robotic surgery and MAO to assess the learning curve and the impact of robotic assistance. Key parameters measured included the accuracy of ostectomy, setup time, and ostectomy efficiency, with data analyzed through a paired-t test to compare the performance between the two groups.

Results

The study indicated a significant reduction in ostectomy time for the experimental group, with improved accuracy and efficiency in ostectomy. The study found that robotic assistance could decrease the risk of complications and enhance surgical outcomes. It also highlighted the presence of an initial learning curve when adopting new robotic technologies, which could be mitigated through adequate training and simulation practices.

Discussion

Using MSRS for MAO could lead to faster early learning curves and increased ostectomy efficiency compared to traditional surgical methods. It demonstrated the potential benefits of integrating robotic systems into craniofacial surgery, suggesting a promising direction for future surgical practices.

Development of a core data set for describing, measuring and reporting the learning curve in studies of novel invasive procedures: study protocol

INTRODUCTION

The introduction of novel surgical techniques and procedures remains poorly regulated and standardised. Although the learning curve associated with invasive procedures is a critical part of innovation, it is currently inconsistently defined, measured and reported. This study aims to develop a core data set that can be applied in all studies describing or measuring the learning curve in novel invasive procedures.

METHODS

A core data set will be developed using methods adapted from the Core Outcome Measures in Effectiveness Trials initiative. The study will involve three phases: (1) Identification of a comprehensive list of data items through (a) an umbrella review of existing systematic reviews on the learning curve in surgery and (b) qualitative interviews with key stakeholders. (2) Key stakeholders (eg, clinical innovators, clinicians, patients, methodologists, statisticians, journal editors and governance representatives) will complete a Delphi survey to score the importance of each data item, generating a shortened list. (3) Consensus meeting(s) with stakeholders to discuss and agree on the final core data set.

ETHICS AND DISSEMINATION

The study is approved by an Institutional Ethics Committee at the University of Bristol (ref: 111362). Participants will complete written informed consent to participate. Dissemination strategies include scientific meeting presentations, peer-reviewed journal publications, patient engagement events, use of social media platforms, workshops and other events.

Implementing the first program of minimally invasive esophagectomy for cancer in Israel: shifting the paradigm in a high-volume center - a cohort study

BACKGROUND

Esophagectomy is associated with significant perioperative morbidity. Limited data are available on the process of implementation of minimally invasive techniques in esophagectomy and related outcomes. The authors sought to describe implementation processes and outcomes following the implementation of the first minimally invasive esophagectomy (MIE) program at a high-volume center in Israel under the mentorship of American early adopters.

METHODS

Patients who underwent esophagectomy for esophageal carcinoma 2011-2022 were included. Early and late cohorts were created for learning curve analysis. Secondary analysis included patients who underwent open esophagectomy 1997-2011.

RESULTS

Overall, 300 patients underwent MIE: three-field MIE (3F-MIE) was performed in 242 (80.7%) patients, two-field MIE (2F-MIE) in 58 (19.3%) patients. Following program implementation in 2012, the number of MIE performed increased during the first 3 years ( n =33, 86.8% in 2015). Among 3F-MIE patients, a higher number of retrieved lymph nodes was reported during later cases (median, IQR1-3 17, 12-23 vs. 12, 8-12, P <0.001) while surgeries required a longer time (median, IQR1-3 300 min, 261-355 vs. 262.5, 239-300, P <0.001). Among 2F-MIE patients, the late cohort had lower rates of prolonged ICU admissions than earlier counterparts ( n =2, 6.9% vs. n =9, 31%, P =0.041), overall and severe 30-day complications ( n =12, 41.4% vs. n =23, 79.3%, P <0.001 and n =7, 24.1% vs. n =23, 79.3%, P =0.003).

CONCLUSIONS

MIE was safely implemented. Nodal yield was higher among MIE patients than open esophagectomy. During the study years, open approach was gradually abandoned in favor of 3F-MIE procedures, while 2F-MIE increased over the course of the last years.

A narrative review of anastomotic leak in the Ivor Lewis esophagectomy: expected, accepted, but preventable

Background and Objective

Anastomotic leak (AL) remains a common and highly morbid complication after Ivor Lewis Esophagectomy. Leak is associated with increased morbidity, mortality, strictures and even cancer recurrence. Unfortunately, despite advances in surgical technique and perioperative care, the reported frequency of AL has remained largely unchanged.

Methods

A PubMed search for all English-language articles that discuss Ivor Lewis esophagectomy, AL, risk factors, and outcomes was conducted from 1901 to 2023 prioritizing research from randomized trials that evaluated outcomes from patients undergoing esophagectomy.

Key Content and Findings

This narrative review will discuss the prevailing literature on AL, risk factors and outcomes with a focus on its relationship to the Ivor Lewis esophagectomy (ILE). In particular, we emphasize that the gastric conduit, as commonly created for most esophagectomy procedures, is inherently vulnerable to ischemia. We will show trends in the literature that have contributed to the high rate of postoperative complications, with a focus on the AL. In addition, we propose that the traditional Ivor Lewis procedure itself is a risk factor for AL. We review a surgical alternative that increases blood supply of the conduit, and is associated with reduced leak, no strictures, and improved surgical outcomes.

Conclusions

Multiple factors contribute to AL after esophagectomy; including several current surgical practices. We believe that some of them, especially the commonly accepted approach to the gastric conduit, can be modified to optimize tissue perfusion. With further investigation, we may reduce the incidence of short and long-term anastomotic complications and improve surgical outcomes.

Determining the frequency of burn wound dressing for clinically competent nursing students: establishing standards based on learning curves

BACKGROUND

The primary objective of clinical practice in nursing education is to achieve mastery of clinical skills through repetitive practice. Therefore, there exists a correlation between the frequency of skill demonstration and clinical competency. This study aimed to address the following question: How many times should a nursing student perform burn wound dressing to attain clinical competency?

METHODS

This time series study was conducted on 41 junior nursing students who were selected through a census sampling method at Neyshabur School of Nursing from spring 2015 to summer 2021. The data collection tool was a researcher-made competency evaluation checklist (CEV). The competency score of each student for each skill demonstraion episode was evaluated using the Competency Evaluation Checklist (CEV) and recorded on the learning curve until a plateau was reached. SPSS16 and repeated measures analysis of variance (ANOVA) were used.

RESULTS

The mean competency score of burn wound dressing was 67.5 ± 11.0 (out of 100) during the first attempt, which increased to 95.9 ± 4.3 by the ninth attempt. The learning curve for the burn wound dressing skill reached a plateau after five attempts. Additionally, by the fifth attempt of dressing the burn wound, all students could accurately identify the depth, extent, and severity of the wound.

CONCLUSIONS

Establishing a standardized frequency for clinical skill performance and ensuring ample practice opportunities can have significant benefits in nursing education systems. These benefits include long-lasting learning, reduced costs, and improved effectiveness. As a result, nurse managers and lecturers should consider the resources available in their educational systems and strive to provide students with adequate opportunities and a supportive environment to practice their skills.

Exploring the learning curve in minimally invasive esophagectomy: a systematic review

Minimally invasive esophagectomy (MIE) has been shown to be superior to open esophagectomy with reduced morbidity, mortality, and comparable lymph node (LN) harvest. However, MIE is technically challenging. This study aims to perform a pooled analysis on the number of cases required to surmount the learning curve (LC), i.e. NLC in MIE. PubMed, Embase, Scopus, and the Cochrane Library were systematically searched for articles from inception to June 2022. Inclusion criteria were articles that reported LC in video-assisted MIE (VAMIE) and/or robot-assisted MIE (RAMIE). Poisson means (95% confidence interval [CI]) was used to determine NLC. Negative binomial regression was used for comparative analysis. There were 41 articles with 45 data sets (n = 7755 patients). The majority of tumors were located in the lower esophagus or gastroesophageal junction (66.7%, n = 3962/5939). The majority of data sets on VAMIE (n = 16/26, 61.5%) used arbitrary analysis, while the majority of data sets (n = 14/19, 73.7%) on RAMIE used cumulative sum control chart analysis. The most common outcomes reported were overall operating time (n = 30/45) and anastomotic leak (n = 28/45). Twenty-four data sets (53.3%) reported on LN harvest. The overall NLC was 34.6 (95% CI: 30.4-39.2), 68.5 (95% CI: 64.9-72.4), 27.5 (95% CI: 24.3-30.9), and 35.9 (95% CI: 32.1-40.2) for hybrid VAMIE, total VAMIE, hybrid RAMIE, and total RAMIE, respectively. NLC was significantly lower for total RAMIE compared to total VAMIE (incidence rate ratio: 0.52, P = 0.032). Studies reporting NLC in MIE are heterogeneous. Further studies should clearly define prior surgical experiences and assess long-term oncological outcomes using non-arbitrary analysis.

Experiences in reverse sequence esophagectomy: a promising alternative for esophageal cancer surgery

OBJECTIVES

McKeown esophagectomy is a standard and significant component of multimodality therapy in esophageal cancer, however, experience in switching the resection and reconstruction sequence in esophageal cancer surgery is not available. Here, we have retrospectively reviewed the experience of reverse sequencing procedure at our institute.

METHODS

We retrospectively reviewed 192 patients who had undergone minimally invasive esophagectomy (MIE) with McKeown esophagectomy between August 2008 and Dec 2015. The patient's demographics and relevant variables were evaluated. The overall survival (OS) and disease-free survival (DFS) were analyzed.

RESULTS

Among the 192 patients, 119 (61.98%) received the reverse sequence MIE (the reverse group) and 73 patients (38.02%) received the standard operation (the standard group). Both patient groups had similar demographics. There were no inter-group differences existed in blood loss, hospital stay, conversion rate, resection margin status, operative complication, and mortality. The reverse group had shorter total operation time (469.83 ± 75.03 vs 523.63 ± 71.93, p < 0.001) and thoracic operation time (181.22 ± 42.79 vs 230.41 ± 51.93, p < 0.001). The 5-year OS and DFS for both groups were similar (44.77% and 40.53% in the reverse group vs 32.66% and 29.42% in the standard group, p = 0.252 and 0.261, respectively). Similar results were observed even after propensity matching.

CONCLUSIONS

The reverse sequence procedure had shorter operation times, especially in the thoracic phase. The reverse sequence MIE is a safe and useful procedure when postoperative morbidity, mortality, and oncological outcomes are considered.

[Robotic esophageal surgery]

Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly becoming established as a standard procedure in surgical centers for esophagectomy in cases of cancer. To date, RAMIE has been shown to have fewer postoperative complications and at least equivalent oncological outcomes compared with open resection. Compared with classical minimally invasive resection, there seem to be fewer cases of postoperative pneumonia after RAMIE. In addition, a higher number of harvested lymph nodes could lead to better oncological long-term outcomes. The learning curve for this complex surgical procedure is relatively shallow but can be greatly reduced at high-volume centers through special training and proctoring programs. Robotic surgical approaches have also been described for other esophageal diseases; however, no clear superiority compared to laparoscopic surgery has so far been shown.

Controversies in the surgical management of esophageal adenocarcinoma

The incidence of esophageal adenocarcinoma (EAC) has risen dramatically over the last decade. Over this same period, our understanding and treatments have been revolutionized. Just over a decade ago, the majority of patients with locally advanced esophageal cancer went directly to surgery and our overall survival was bleak. Our current strategy for locally advanced esophageal adenocarcinoma is a multi-disciplinary approach. This approach consists of chemotherapy plus or minus radiation followed by surgical resection followed by adjuvant immunotherapy with the presence of any residual disease. Therefore, now more than ever, the goals of surgery are to minimize morbidity, provide aggressive local control and allow patients to receive to quickly recover so they can receive adjuvant systemic therapy. Surgery continues to play a crucial role in the multi-disciplinary approach to EAC. This review will highlight the on-going areas of controversy in surgical treatment. These controversies are around surgical selection, perioperative decision making and the role of surgery. Specifically, there are controversies in the type of surgical approach offered. This review will discuss the benefits of minimally invasive versus open esophagectomy. The indications for gastrectomy versus esophagectomy in patients with gastroesophageal junction EAC. Further, at the time of operation, there is still debate and on-going trials addressing the addition of a pyloric intervention. Lastly, as we push the limits of systemic therapy, there are those who may not even need a surgical resection. This review will cover the most recent data on selective esophageal resection and the concerns regarding this approach.

Implementation of minimally invasive Ivor Lewis esophagectomy: learning curve of a single high-volume center

Open esophagectomy is considered to be the main surgical procedure in the world for esophageal cancer treatment. Implementing a new surgical technique is associated with learning curve morbidity. The objective of this study is to determine the learning curve based on anastomotic leakage (AL) after implementing minimally invasive Ivor Lewis esophagectomy (MI-ILE) in January 2015. All 257 patients who underwent MI-ILE in a single high-volume center between January 2015 and December 2020 were retrospectively included in this study. The learning curve was evaluated using the standard CUSUM analysis with an expected AL rate of 11%. Secondary outcome parameters were postoperative complications, textbook outcome, and lymph node yield divided by the year of operation. Hierarchical binary logistic regression analysis was used to check for potential confounding variables. The CUSUM analysis showed a learning curve of 179 cases. The mean AL rate decreased from 33.3% in 2015 to 9.5% in 2020 (P = 0.007). There was an increase in the mean lymph node yield from 21 in 2018 to 28 in 2019 (P < 0.001) and textbook outcome from 37.3% in 2015 to 66.7% in 2020 (P = 0.005). A newly implemented MI-ILE has a learning curve of 179 patients based on a reference AL rate of 11% using the CUSUM method. Whether future generation surgeons will show similar learning curve numbers, implicating continuous development of different introduction programs of new techniques, will have to be the focus of future research.

Introducing robotic oesophagectomy into an Australian practice: an assessment of the early procedural outcomes and learning curve

BACKGROUND

Robotic oesophagectomy (RAMIO) is a novel procedure in Australia and New Zealand. We aimed to report the early operative and clinical outcomes achieved during the introduction of RAMIO into the practice of a single Australian surgeon and benchmark these against outcomes of patients receiving conventional minimally invasive oesophagectomy (MIO) by the same surgeon.

METHODS

Data on all patients undergoing RAMIO, performed by a single high-volume Australian surgeon, were collected from a prospectively maintained database. Operative, clinical and surgical quality outcomes were benchmarked on a univariable basis against those of patients receiving MIO. Learning curves were computed using quadratic and linear regression of operating times on case-numbers and compared using Cox regression modelling.

RESULTS

290 patients (237 MIO, 53 RAMIO (47% Ivor-Lewis, 53% McKeon oesophagectomy)) were included. Compared with MIO, the median thoracic operating time was 20 min longer for RAMIO (P = 0.03). Following RAMIO, there was less blood loss (P < 0.01) and a shorter length of stay (P < 0.01).There were no differences in morbidity and quality of surgery following RAMIO compared with MIO. There were no deaths following RAMIO. Having progressed from MIO, the operating times for RAMIO improved after 22 cases compared with MIO (110 cases) (HR 0.70 (0.51-0.93), P = 0.01).

CONCLUSION

With careful implementation, RAMIO may be safely performed within the Australian setting and is associated with a modest increase in procedure duration, but less blood loss and shorter length of stay compared with conventional MIO.

Learning Curve of Laparoscopic Gastrectomy: A Multicenter Study

OBJECTIVE

To evaluate the learning curve of laparoscopic gastrectomy (LG) after an implementation program.

BACKGROUND

Although LG is increasingly being performed worldwide, little is known about the learning curve.

METHODS

Consecutive patients who underwent elective LG for gastric adenocarcinoma with curative intent in each of the 5 highest-volume centers in the Netherlands were enrolled. Generalized additive models and a 2-piece model with a break point were used to determine the learning curve length. Analyses were corrected for casemix and were performed for LG and for the subgroups distal gastrectomy (LDG) and total gastrectomy (LTG). The learning curve effect was assessed for (1) anastomotic leakage; and (2) the occurrence of postoperative complications, conversions to open surgery, and short-term oncological parameters.

RESULTS

In total 540 patients were included for analysis, 108 patients from each center; 268 patients underwent LDG and 272 underwent LTG. First, for LG, no learning effect regarding anastomotic leakage could be identified: the rate of anastomotic leakage initially increased, then reached a plateau after 36 cases at 10% anastomotic leakage. Second, the level of overall complications reached a plateau after 20 cases, at 38% overall complications, and at 5% conversions. For both LDG and LTG, each considered separately, fluctuations in secondary outcomes and anastomotic leakage followed fluctuations in casemix.

CONCLUSION

On the basis of our study of the first 108 procedures of LG in 5 high-volume centers with well-trained surgeons, no learning curve effect could be identified regarding anastomotic leakage. A learning curve effect was found with respect to overall complications and conversion rate.

Impact of Weekend Effect on Short- and Long-Term Survival of Patients Undergoing Esophagectomy for Cancer: A Population-Based, Inverse Probability of Treatment-Weighted Analysis

BACKGROUND

We examined the impact of the weekend effect on the survival outcomes of patients undergoing elective esophagectomy for cancer.

METHODS

This was a retrospective analysis of a nationwide, health administrative dataset that included all patients (n = 3235) who had undergone elective esophagectomy for cancer in Taiwanese hospitals between 2008 and 2015. Patients were categorized according to the day of surgery (weekday group: surgical procedures starting Monday through Friday, n = 3148; weekend group: surgical procedures starting on Saturday or Sunday, n = 87). Inverse probability of treatment weighting (IPTW) using the propensity score was used to account for selection bias due to baseline differences.

RESULTS

After IPTW, patients undergoing esophagectomy on weekends had a higher 90-days mortality rate compared with those undergoing surgery on a weekday (10.5% vs. 5.5%, respectively, P < 0.001). After controlling for potential confounders, weekend surgery was identified as an independent adverse predictor of 2-years, overall survival [hazard ratio (HR) = 1.38, P < 0.001]. Importantly, inferior weekend outcomes were especially evident in certain subgroups, including patients aged > 60 years (HR = 1.61, P < 0.001), as well as those with a high burden of comorbidities (HR = 1.32, P < 0.001), advanced tumor stage (HR = 1.50, P < 0.001), histological diagnosis of squamous cell carcinoma (HR = 1.20, P < 0.001), and treated with minimally invasive esophagectomy (HR = 1.26, P < 0.001).

CONCLUSIONS

Elective esophagectomy for cancer during weekends has an adverse impact on short- and long-term survival.

Why pay more for robot in esophageal cancer surgery?

Esophagectomy is the gold standard for the treatment of resectable esophageal cancer. Traditionally, it is performed through a laparotomy and a thoracotomy, and is associated with high rates of postoperative complications and mortality. The advent of robotic surgery has represented a technological evolution in the field of esophageal cancer treatment. Robot-assisted Minimally Invasive Esophagectomy (RAMIE) has been progressively widely adopted following the first reports on the safety and feasibility of this procedure in 2004. The robotic approach has better short-term postoperative outcomes than open esophagectomy, without jeopardizing oncologic radicality. The results of the comparison between RAMIE and conventional minimally invasive esophagectomy are less conclusive. This article will focus on the role of RAMIE in the current clinical scenario with particular attention to its possible benefits and perspectives.

Worldwide Techniques and Outcomes in Robot-assisted Minimally Invasive Esophagectomy (RAMIE): Results From the Multicenter International Registry

OBJECTIVE

This international multicenter study by the Upper GI International Robotic Association aimed to gain insight in current techniques and outcomes of RAMIE worldwide.

BACKGROUND

Current evidence for RAMIE originates from single-center studies, which may not be generalizable to the international multicenter experience.

METHODS

Twenty centers from Europe, Asia, North-America, and South-America participated from 2016 to 2019. Main endpoints included the surgical techniques, clinical outcomes, and early oncological results of ramie.

RESULTS

A total of 856 patients undergoing transthoracic RAMIE were included. Robotic surgery was applied for both the thoracic and abdominal phase (45%), only the thoracic phase (49%), or only the abdominal phase (6%). In most cases, the mediastinal lymphadenectomy included the low paraesophageal nodes (n=815, 95%), subcarinal nodes (n = 774, 90%), and paratracheal nodes (n = 537, 63%). When paratracheal lymphadenectomy was performed during an Ivor Lewis or a McKeown RAMIE procedure, recurrent laryngeal nerve injury occurred in 3% and 11% of patients, respectively. Circular stapled (52%), hand-sewn (30%), and linear stapled (18%) anastomotic techniques were used. In Ivor Lewis RAMIE, robot-assisted hand-sewing showed the highest anastomotic leakage rate (33%), while lower rates were observed with circular stapling (17%) and linear stapling (15%). In McKeown RAMIE, a hand-sewn anastomotic technique showed the highest leakage rate (27%), followed by linear stapling (18%) and circular stapling (6%).

CONCLUSION

This study is the first to provide an overview of the current techniques and outcomes of transthoracic RAMIE worldwide. Although these results indicate high quality of the procedure, the optimal approach should be further defined.

Short-term outcomes of Ivor Lewis vs. McKeown esophagectomy: A meta-analysis

OBJECTIVE

The objective of this article is to assess the rate of anastomotic leak and other perioperative outcomes in patients undergoing esophagectomy with either thoracic or cervical anastomosis.

METHODS

This meta-analysis was conducted by searching relevant literature studies in Web of Science, Cochrane Library, PubMed, and Embase databases. Articles that included patients undergoing esophagectomy and compared perioperative outcomes of McKeown with Ivor Lewis procedures were included. The primary outcome parameter was anastomotic leak, and secondary outcome parameters were grade ≥2 anastomotic leak, chylothorax, recurrent laryngeal nerve injury, hospital length of stay, intensive care unit (ICU) length of stay, postoperative mortality rate, operative time, blood loss, R0 resection rate, and lymph nodes examined.

RESULTS

A total of eight studies, with 3,291 patients (1,857 Ivor Lewis procedure and 1,434 McKeown procedure) were eligible for analysis. Meta-analysis showed that Ivor Lewis procedure was associated with lower rate of anastomosis leak of all grades [risk ratio (RR), 0.67; 95% confidence interval (CI), 0.55-0.82; P = 0.0001], lower rate of recurrent laryngeal nerve injury (RR, 0.14; 95% CI, 0.08-0.25), and shorter length of hospital stay (weighted mean difference, 0.13; 95% CI, 0.04-0.22). Grade ≥2 anastomotic leak, chylothorax, ICU length of stay, postoperative mortality rate, operative time, blood loss, R0 resection rate, and lymph nodes examined were similar between the two groups.

CONCLUSIONS

Although all grades of anastomotic leak and recurrent laryngeal nerve injury are higher in the McKeown procedure, this meta-analysis supports similar short-term outcomes and oncological efficacy between Ivor Lewis and McKeown esophagectomy.

Ten years of IRCAD, Barretos, SP, Brazil

Minimally invasive surgery represented a significant milestone in modern surgery; however, continuous innovation and the emergence of new technologies pose new challenges in terms of surgical learning curves since new interventions are associated with increased surgical complexity and a higher risk of complications. For this reason, surgeons are aware of the beneficial effects of "learning before doing" and the importance of safely implementing new surgical procedures in order to obtain better patient outcomes. Considered the largest Latin American training center in minimally invasive surgery, IRCAD Barretos, São Paulo, Brazil, makes it possible to acquire surgical skills through training in different and the most complex areas of medicine, providing the experience of real and simulated situations, with focus on innovation. The center possesses state-of-the-art infrastructure and technology, with a very high-level teaching staff and an affectionate and hospitable reception. Since its inauguration, in 2011, the center has already qualified numerous professionals and has placed the country in a privileged position in terms of surgical knowledge. The present article describes the activities developed over these ten years of the institute in Brazil as the largest training center for surgeons of the continent in order to address the importance of surgical skills training.

Improved anastomotic leakage rates after the "flap and wrap" reconstruction in Ivor Lewis esophagectomy for cancer

Anastomotic leakage after esophagectomy has serious consequences. In Ivor Lewis esophagectomy, a shorter and possibly better vascularized gastric conduit is created than in McKeown esophagectomy. Intrathoracic anastomoses can additionally be wrapped in omentum and concealed behind the pleura ("flap and wrap" reconstruction). Aims of this observational study were to assess the anastomotic leakage incidence after transhiatal esophagectomy (THE), McKeown esophagectomy (McKeown), Ivor Lewis esophagectomy (IL) without "flap and wrap" reconstruction, and IL with "flap and wrap" reconstruction. Consecutive patients undergoing esophagectomy at a tertiary referral center between January 2013 and April 2019 were included. Primary outcome was the anastomotic leakage rate. Secondary outcomes were postoperative outcomes, mortality, and 3-year overall survival. A total of 463 patients were included. The anastomotic leakage incidence after THE (n = 37), McKeown (n = 97), IL without "flap and wrap" reconstruction (n = 39), and IL with "flap and wrap" reconstruction (n = 290) were 24.3, 32.0, 28.2, and 7.2% (P < 0.001). THE and IL with "flap and wrap" reconstruction required fewer reoperations for anastomotic leakage (0 and 1.4%) than McKeown and IL without "flap and wrap" reconstruction (6.2 and 17.9%, P < 0.001). Fewer anastomotic leakages are observed after Ivor Lewis esophagectomy with "flap and wrap" reconstruction compared to transhiatal, McKeown and Ivor Lewis esophagectomy without "flap and wrap" reconstruction. The "flap and wrap" reconstruction seems a promising technique to further reduce anastomotic leakages and its severity in esophageal cancer patients who have an indication for Ivor Lewis esophagectomy.

Today's Mistakes and Tomorrow's Wisdom in the Surgical Treatment of Barrett's Adenocarcinoma

Background

Barrett's esophagus is a premalignant condition caused by longstanding gastroesophageal reflux disease and may progress to low-grade dysplasia, high-grade dysplasia (HGD), and finally esophageal adenocarcinoma.

Summary

Barrett's adenocarcinoma can be treated either by endoscopic or surgical resection, depending on the clinical staging. Endoscopic resection is a safe and adequate treatment option for HGD, mucosal tumors, and low-risk submucosal tumors. Its role in the treatment of high-risk submucosal tumors and the role of organ-preserving sentinel node navigated surgery are still under investigation. Esophagectomy with neoadjuvant chemoradiation or perioperative chemotherapy is considered the standard of care for locally advanced Barrett's adenocarcinoma. Regarding operative technique, there is no proven superiority of one technique over another, although a minimally invasive transthoracic technique seems most commonly applied nowadays. In this review, state-of-the-art evidence and future expectations are presented regarding indications for resection, neoadjuvant or perioperative therapy, type of surgery, and postoperative follow-up for Barrett's adenocarcinoma.

Key Messages

In Barrett's adenocarcinoma, endoscopic resection is the standard treatment option for low-risk mucosal and submucosal tumors. For high-risk submucosal tumors, endoscopic submucosal dissection with close surveillance and sentinel node navigated surgery are currently being studied. For locally advanced cancer, a multimodal therapy including esophagectomy is the standard of care. Nowadays, in high-volume centers, a minimally invasive transthoracic esophagectomy with an intrathoracic anastomosis is the most common procedure for Barrett's adenocarcinoma.

Robotic-assisted minimally invasive Ivor Lewis esophagectomy within the prospective multicenter German da Vinci Xi registry trial

Abstract

Purpose

Robotic-assisted minimally invasive esophagectomy (RAMIE) has become one standard approach for the operative treatment of esophageal tumors at specialized centers. Here, we report the results of a prospective multicenter registry for standardized RAMIE.

Methods

The German da Vinci Xi registry trial included all consecutive patients who underwent RAMIE at five tertiary university centers between Oct 17, 2017, and Jun 5, 2020. RAMIE was performed according to a standard technique using an intrathoracic circular stapled esophagogastrostomy.

Results

A total of 220 patients were included. The median age was 64 years. Total minimally invasive RAMIE was accomplished in 85.9%; hybrid resection with robotic-assisted thoracic approach was accomplished in an additional 11.4%. A circular stapler size of ≥28 mm was used in 84%, and the median blood loss and operative time were 200 (IQR: 80–400) ml and 425 (IQR: 335–527) min, respectively. The rate of anastomotic leakage was 13.2% (n=29), whereas the two centers with >70 cases each had rates of 7.0% and 12.0%. Pneumonia occurred in 19.5% of patients, and the 90-day mortality was 3.6%. Cumulative sum analysis of the operative time indicated the end of the learning curve after 22 cases.

Conclusions

High-quality multicenter registry data confirm that RAMIE is a safe procedure and can be reproduced with acceptable leak rates in a multicenter setting. The learning curve is comparably low for experienced robotic surgeons.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02520-w.

Learning Curves of Ivor Lewis Totally Minimally Invasive Esophagectomy by Hospital and Surgeon Characteristics: A Retrospective Multinational Cohort Study

OBJECTIVE

To describe the pooled learning curves of Ivor Lewis totally minimally invasive esophagectomy (TMIE) in hospitals stratified by predefined hospital- and surgeon-related factors.

BACKGROUND

Ivor Lewis (TMIE is known to have a long learning curve which is associated with considerable learning associated morbidity. It is unknown whether hospital and surgeon characteristics are associated with more efficient learning.

METHODS

A retrospective analysis of prospectively collected data of consecutive Ivor Lewis TMIE patients in 14 European hospitals was performed. Outcome parameters used as proxy for efficient learning were learning curve length, learning associated morbidity, and the plateau level regarding anastomotic leakage and textbook outcome. Pooled incidences were plotted for the factor-based subgroups using generalized additive models and 2-phase models. Casemix predicted outcomes were plotted and compared with observed outcomes. The investigated factors included annual volume, TMIE experience, clinic visits, courses and fellowships followed, and proctor supervision.

RESULTS

This study included 2121 patients. The length of the learning curve was shorter for centers with an annual volume >50 compared to centers with an annual volume <50. Analysis with an annual volume cut-off of 30 cases showed similar but less pronounced results. No outcomes suggesting more efficient learning were found for longer experience as consultant, visiting an expert clinic, completing a minimally invasive esophagectomy fellowship or implementation under proctor supervision.

CONCLUSIONS

More efficient learning was observed in centers with higher annual volume. Visiting an expert clinic, completing a fellowship, or implementation under a proctor's supervision were not associated with more efficient learning.

Improved clinical and survival outcomes after esophagectomy for cancer over 25 years

BACKGROUND

In recent decades, there have been major developments in the curative treatment of esophageal cancer, such as the implementation of PET/CT, neoadjuvant chemoradiotherapy, minimally invasive surgery and postoperative care programs. This observational study examined clinical and survival outcomes after esophagectomy for cancer over 25 years.

METHODS

Consecutive patients who underwent esophagectomy for cancer at a tertiary referral center between 1993 and 2018 were selected from a prospectively maintained database. Patients were assigned to five periods: 1993-1997, 1998-2002, 2003-2007, 2008-2012, and 2013-2017. The primary outcome was the 5-year overall survival (OS) using Kaplan-Meier log-rank tests for trends.

RESULTS

A total of 1616 patients were analyzed. The median follow-up of surviving patients was 91.0 months (IQR 62.6-127.5).The 5-year overall survival improved gradually from 32.8 to 48.2% over 25 years, P<.001. Hospital length of stay reduced from 16 days (median, IQR 14-24) in 1993-1997 to 11 days (IQR 8-18) in 2013-2017, P<.001. No decrease in mortality was encountered over 25 years, although over the last 5 years, in-hospital and 90-day mortality dropped from 4.2% and 8.3% in 2013 to 0% in 2017, P<.05. Anastomotic leakages reduced from 26.4 to 9.7% between 2013 and 2017, P<.001.

CONCLUSIONS

Over the last 25 years, clinical outcomes and 5-year overall survival significantly improved in patients who underwent esophagectomy for cancer at this tertiary referral center.

Surgical outcomes after totally minimally invasive Ivor Lewis esophagectomy. A systematic review and meta-analysis

BACKGROUND

A transthoracic esophagectomy is associated with high rates of morbidity. Minimally invasive esophagectomy has emerged to decrease such morbidity. The aim of this study was to accurately determine surgical outcomes after totally minimally invasive Ivor-Lewis Esophagectomy (TMIE).

METHODS

A systematic literature search was performed to identify original articles analyzing patients who underwent TMIE. Main outcomes included overall morbidity, major morbidity, pneumonia, arrhythmia, anastomotic leak, chyle leak, and mortality. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for each analyzed outcome.

RESULTS

A total of 5619 patients were included for analysis; 4781 (85.1%) underwent a laparoscopic/thoracoscopic esophagectomy and 838 (14.9%) a robotic-assisted esophagectomy. Mean age of patients was 63.5 (55-67) years and 75.8% were male. Overall morbidity and major morbidity rates were 39% (95% CI, 33%-45%) and 20% (95% CI, 13%-28%), respectively. Postoperative pneumonia and arrhythmia rates were 10% (95% CI, 8%-13%) and 12% (95% CI, 8%-17%), respectively. Anastomotic leak rate across studies was 8% (95% CI, 6%-10%). Chyle leak rate was 3% (95% CI, 2%-5%). Mortality rate was 2% (95% CI, 2%-2%). Median ICU stay and length of hospital stay were 2 (1-4) and 11.2 (7-20) days, respectively.

CONCLUSIONS

Totally minimally invasive Ivor-Lewis esophagectomy is a challenging procedure with high morbidity rates. Strategies to enhance postoperative outcomes after this operation are still needed.

Robot-assisted versus video-assisted thoraco-laparoscopic McKeown's esophagectomy for esophageal cancer: a propensity score-matched analysis of minimally invasive approaches

Minimally invasive esophagectomy for esophageal cancer decreases overall complication rate and leads to faster postoperative recovery. Robot-assisted minimally invasive esophagectomy is becoming more common. Its three-dimensional view and wristed instruments may provide advantages over traditional thoraco-laparoscopic techniques. There are limited studies comparing robotic and conventional thoraco-laparoscopic esophagectomy. This study aimed to evaluate short-term outcomes of robot-assisted McKeown esophagectomy (RAME) and video-assisted McKeown esophagectomy (VAME). All consecutive patients undergoing minimally invasive McKeown esophagectomy for middle and distal third esophageal cancer between January 2016 and December 2018 at our center were included in this study. Data on baseline characteristics, pathological data and short-term outcomes were collected in a dedicated database. Postoperative complications were defined as per recommendations of Esophagectomy Complications Consensus Group. Histopathologic assessment was performed as per College of American Pathologists guidelines. Propensity score matching was performed for comparison between RAME and VAME groups using age, gender, performance status, American Society of Anesthesiologists grade, body mass index, Charlson Index, tumor location, clinical tumor stage, and neoadjuvant treatment as covariates. A total of 74 patients were included, 25 of whom underwent RAME and 49 underwent VAME. Propensity score matching on 1:1 basis produced 25 pairs of patients, comparable in terms of baseline characteristics. Total operative time and estimated blood loss was similar between the two groups. Length of hospital stay was significantly lower in RAME group. Major postoperative complications (Clavien-Dindo grade ≥ 3A) were more common in VAME group, but not statistically significant. Median number of harvested lymph nodes and R0 resection rate did not differ in between the two groups. In our experience, robot-assisted McKeown esophagectomy was comparable to video-assisted McKeown esophagectomy in terms of safety, feasibility and oncologic adequacy. Use of the robot was associated with reduced hospital stay. Further randomized controlled studies with larger patient samples are needed to compare the two.

European consensus on essential steps of Minimally Invasive Ivor Lewis and McKeown Esophagectomy through Delphi methodology

BACKGROUND

Minimally invasive esophagectomy (MIE) is a complex and technically demanding procedure with a long learning curve, which is associated with increased morbidity and mortality. To master MIE, training in essential steps is crucial. Yet, no consensus on essential steps of MIE is available. The aim of this study was to achieve expert consensus on essential steps in Ivor Lewis and McKeown MIE through Delphi methodology.

METHODS

Based on expert opinion and peer-reviewed literature, essential steps were defined for Ivor Lewis (IL) and McKeown (McK) MIE. In a round table discussion, experts finalized the lists of steps and an online Delphi questionnaire was sent to an international expert panel (7 European countries) of minimally invasive upper GI surgeons. Based on replies and comments, steps were adjusted and rephrased and sent in iterative fashion until consensus was achieved.

RESULTS

Two Delphi rounds were conducted and response rates were 74% (23 out of 31 experts) for the first and 81% (27 out of 33 experts) for the second round. Consensus was achieved on 106 essential steps for both the IL and McK approach. Cronbach's alpha in the first round was 0.78 (IL) and 0.78 (McK) and in the second round 0.92 (IL) and 0.88 (McK).

CONCLUSIONS

Consensus among European experts was achieved on essential surgical steps for both Ivor Lewis and McKeown minimally invasive esophagectomy.

The learning curve of robot-assisted vitreoretinal surgery - A randomized trial in a simulated setting

PURPOSE

To investigate the learning curve of robot-assisted vitreoretinal surgery compared to manual surgery in a simulated setting.

METHODS

The study was designed as a randomized controlled longitudinal study. Eight ophthalmic trainees in the 1st or 2nd year of their specialization were included. The participants were randomized to either manual or robot-assisted surgery. Participants completed repetitions of a test consisting of three vitreoretinal modules on the Eyesi virtual reality simulator. The primary outcome measure was time to learning curve plateau (minutes) for total test score. The secondary outcome measures were instrument movement (mm), tissue treatment (mm² ) and time with instruments inserted (seconds).

RESULTS

There was no significant difference in time to learning curve plateau for robot-assisted vitreoretinal surgery compared to manual. Robot-assisted vitreoretinal surgery was associated with less instrument movements (i.e. improved precision), -0.91 standard deviation (SD) units (p < 0.001). Furthermore, robot-assisted vitreoretinal surgery was associated with less tissue damage when compared to manual surgery, -0.94 SD units (p = 0.002). Lastly, robot-assisted vitreoretinal surgery was slower than manual surgery, 0.93 SD units (p < 0.001).

CONCLUSIONS

There was no significant difference between the lengths of the learning curves for robot-assisted vitreoretinal surgery compared to manual surgery. Robot-assisted vitreoretinal surgery was more precise, associated with less tissue damage, and slower.

Peri-operative approach to esophagectomy: a narrative review from the anesthesiological standpoint

Objective

This review summarizes the peri-operative anesthesiological approaches to esophagectomy considering the best up-to-date, evidence-based medicine, discussed from the anesthesiologist’s standpoint.

Background

Esophagectomy is the only curative therapy for esophageal cancer. Despite the many advancements made in the surgical treatment of this tumour, esophagectomy still carries a morbidity rate reaching 60%. Patients undergoing esophagectomy should be referred to high volume centres where they can receive a multidisciplinary approach to treatment, associated with better outcomes. The anesthesiologist is the key figure who should guide the peri-operative phase, from diagnosis through to post-surgery rehabilitation. We performed an updated narrative review devoted to the study of anesthesia management for esophagectomy in cancer patients.

Methods

We searched MEDLINE, Scopus and Google Scholar databases from inception to May 2021. We used the following terms: “esophagectomy”, “esophagectomy AND pre-operative evaluation”, “esophagectomy AND protective lung ventilation”, “esophagectomy AND hemodynamic monitoring” and “esophagectomy AND analgesia”. We considered only articles with abstract written in English and available to the reader. We excluded single case-reports.

Conclusions

Pre-operative anesthesiological evaluation is mandatory in order to stratify and optimize any medical condition. During surgery, protective ventilation and judicious fluid management are the cornerstones of intraoperative “protective anesthesia”. Post-operative care should be provided by an intensive care unit or high-dependency unit depending on the patient’s condition, the type of surgery endured and the availability of local resources. The provision of adequate post-operative analgesia favours early mobilization and rapid recovery. Anesthesiologist has an important role during the peri-operative care for esophagectomy. However, there are still some topics that need to be further studied to improve the outcome of these patients.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Minimally invasive esophagectomy learning curves with different types of background experience

BACKGROUND

Minimally invasive esophagectomy (MIE) is a complex procedure with learning associated morbidity. The aim was to evaluate the learning curve for MIE focusing on short-term outcomes in two settings: (I) experienced MIE surgeon in new hospital (Hospital 1); (II) surgeons experienced with open esophagectomy and minimally invasive surrogate surgery (Hospital 2).

METHODS

In Hospital 1 and Hospital 2, on intent-to-treat basis number of MIEs were 132 and 57, respectively. The primary outcomes were major complications and anastomosis leaks. Secondary outcomes were operative time, blood loss, lymph node yield, hospital stay and 1-year mortality. Length of learning curves were analyzed with risk-adjusted cumulative sum (RA-CUSUM) method.

RESULTS

In Hospital 1, major complication and anastomosis leak rates were 9.8% and 4.5%, 22.8% and 12.3% in Hospital 2, respectively. In Hospital 1, complication and leak rates remained stable. In Hospital 2, improvement occurred after 34 cases in major complications and 29 cases in leaks. Of secondary outcomes, improvements were seen in Hospital 1 in operative time after 61, blood loss after 86, lymph node yield after 52, hospital stay after 19 and 1-year mortality after 24 cases. In Hospital 2, improvement occurred in operative time after 30, blood loss after 15, lymph node yield after 45, hospital stay after 50 and 1-year mortality after 15 cases.

CONCLUSIONS

According to this study, learning phase of the individual surgeon determines the outcomes of MIE, not the institutional learning phase.

Risk Factors for Failure of Direct Oral Feeding Following a Totally Minimally Invasive Esophagectomy

Recently, it has been shown that directly starting oral feeding (DOF) from postoperative day one (POD1) after a totally minimally invasive Ivor-Lewis esophagectomy (MIE-IL) can further improve postoperative outcomes. However, in some patients, tube feeding by a preemptively placed jejunostomy is necessary. This single-center cohort study investigated risk factors associated with failure of DOF in patients that underwent a MIE-IL between October 2015 and April 2021. A total of 165 patients underwent a MIE-IL, in which DOF was implemented in the enhanced recovery after surgery program. Of these, 70.3% (n = 116) successfully followed the nutritional protocol. In patients in which tube feeding was needed (29.7%; n = 49), female sex (compared to male) (OR 3.5 (95% CI 1.5-8.1)) and higher ASA scores (III + IV versus II) (OR 2.2 (95% CI 1.0-4.8)) were independently associated with failure of DOF for any cause. In case of failure, this was either due to a postoperative complication (n = 31, 18.8%) or insufficient caloric intake on POD5 (n = 18, 10.9%). In the subgroup of patients with complications, higher ASA scores (OR 2.8 (95% CI 1.2-6.8)) and histological subtypes (squamous-cell carcinoma versus adenocarcinoma and undifferentiated) (OR 5.2 (95% CI 1.8-15.1)) were identified as independent risk factors. In the subgroup of patients with insufficient caloric intake, female sex was identified as a risk factor (OR 5.8 (95% CI 2.0-16.8)). Jejunostomy-related complications occurred in 17 patients (10.3%). In patients with preoperative risk factors, preemptively placing a jejunostomy may be considered to ensure that nutritional goals are met.

Meta-analysis of randomized controlled trials and individual patient data comparing minimally invasive with open oesophagectomy for cancer

BACKGROUND

Minimally invasive oesophagectomy (MIO) for oesophageal cancer may reduce surgical complications compared with open oesophagectomy. MIO is, however, technically challenging and may impair optimal oncological resection. The aim of the present study was to assess if MIO for cancer is beneficial.

METHODS

A systematic literature search in MEDLINE, Web of Science and CENTRAL was performed and randomized controlled trials (RCTs) comparing MIO with open oesophagectomy were included in a meta-analysis. Survival was analysed using individual patient data. Random-effects model was used for pooled estimates of perioperative effects.

RESULTS

Among 3219 articles, six RCTs were identified including 822 patients. Three-year overall survival (56 (95 per cent c.i. 49 to 62) per cent for MIO versus 52 (95 per cent c.i. 44 to 60) per cent for open; P = 0.54) and disease-free survival (54 (95 per cent c.i. 47 to 61) per cent versus 50 (95 per cent c.i. 42 to 58) per cent; P = 0.38) were comparable. Overall complication rate was lower for MIO (odds ratio 0.33 (95 per cent c.i. 0.20 to 0.53); P < 0.010) mainly due to fewer pulmonary complications (OR 0.44 (95 per cent c.i. 0.27 to 0.72); P < 0.010), including pneumonia (OR 0.41 (95 per cent c.i. 0.22 to 0.77); P < 0.010).

CONCLUSION

MIO for cancer is associated with a lower risk of postoperative complications compared with open resection. Overall and disease-free survival are comparable for the two techniques.

LAY SUMMARY

Oesophagectomy for cancer is associated with a high risk of complications. A minimally invasive approach might be less traumatic, leading to fewer complications and may also improve oncological outcome. A meta-analysis of randomized controlled trials comparing minimally invasive to open oesophagectomy was performed. The analysis showed that the minimally invasive approach led to fewer postoperative complications, in particular, fewer pulmonary complications. Survival after surgery was comparable for the two techniques.

Thirty years of esophageal cancer surgery in Oulu University Hospital

Background

Esophagectomy is the mainstay of surgical treatment of esophageal cancer, but involves high operative risk. The aim of this study was to review the evolution surgical treatment of esophageal cancer in Northern Finland, with introduction of minimally invasive techniques.

Methods

All elective esophagectomies performed in Oulu University Hospital between years 1987 and 2020 were included. Treatment strategies were compared to current guidelines including staging and use of neoadjuvant therapy, and benchmark values including postoperative morbidity, hospital stay, readmissions and 90-day mortality. Long-term survival was compared to previous national studies.

Results

Between years 1987 and 2020 a total of 341 underwent an esophagectomy. Transhiatal resection was performed to 167 (49.3%), Ivor Lewis to 129 (38.1%) and McKeown to 42 (12.4%) patients. MIE was performed to 49 (14.5%) patients. During the past four years 83.7% of locally advanced diseases received neoadjuvant treatment. Since 1987, gradual improvements have occurred especially in incidence of pleural effusion requiring additional drainage procedure (highest in 2011–2013 and in last four years 14.0%), recurrent nerve injuries (highest in 2008–2010 29.4% and lowest in 2017–2020 1.8%) and in 1-year survival rate (1987–1998 68.4% vs. 2017–2020 82.1%). No major changes in comorbidity, complication rate, anastomosis leaks, hospital stay or postoperative mortality were seen.

Conclusions

Esophageal cancer surgery has gone through major changes over three decades. Current guideline-based treatment has resulted with progressive improvement in mid- and long-term survival. However, despite modern protocol, no major improvement has occurred for example in major complications, anastomosis leak rates or hospital stay.

Learning Curve for Lymph Node Dissection Around the Recurrent Laryngeal Nerve in McKeown Minimally Invasive Esophagectomy

Background

Compared to open esophagectomy (OE), minimally invasive esophagectomy (MIE) is associated with lower morbidity and mortality. However, lymph node (LN) dissection around the recurrent laryngeal nerve (RLN) is still an important factor that affects the length of the learning curve of MIE. This study aims to evaluate the surgical outcomes of the first nearly 5-year period and explore the learning curve for LN dissection around the RLN in McKeown MIE by a new single surgical team.

Methods

A total of 285 consecutive patients who underwent McKeown MIE between March 2016 and September 2020 were included at our institution. According to the cumulative sum (CUSUM) analysis of LN dissection around the RLN, the patients were divided into three groups: exploration period, adjustment period, and stable period. We assessed the impact of surgical proficiency on postoperative outcomes and explored the learning curve for LN dissection around the RLN in McKeown MIE.

Results

The CUSUM graph showed that a point of upward inflection for LN dissection around the RLN was observed in 151 cases. After 151 cases, LNs around the right and left RLNs were dissected thoroughly compared to the exploration and adjustment period (P = 0.010 and P = 0.012, respectively), and the postoperative incidence of hoarseness significantly decreased from 11.1 to 1.5% (P<0.001).

Conclusions

Our study results revealed that not only are the LN, around the RLN, sufficiently dissected but also the incidence of hoarseness significantly decreased in the stable phase. Consequently, the learning curve length was approximately 151 cases for LN dissection around the RLN in McKeown MIE.

Side-to-side esophagogastric anastomosis for minimally invasive Ivor-Lewis esophagectomy: operative technique and short-term outcomes

Totally minimally invasive Ivor-Lewis esophagectomy (TMIIL) is associated to lower rate of post-operative complication, decreases length of hospital stay and improves quality of life compared to open approach. Nevertheless, adaptation of TMIIL still proceeds at slow pace, mainly due to the difficulty to perform the intra-thoracic anastomosis and heterogeneity of surgical techniques. We present our experience with TMIIL utilizing a stapled side-to-side anastomosis. We retrospectively evaluated 36 patients who underwent a planned TMIIL from January 2017 to September 2020. Esophagogastric anastomoses were performed using a 3-cm linear-stapled side-to-side technique. General features, operative techniques, pathology data and short-term outcomes were analyzed. The median operative time was 365 min (ranging from 240 to 480 min) with a median blood loss of 100 ml (50–1000 ml). The median overall length of stay was 13 (7–64) days and in-hospital mortality rate was 2.8%. Two patients (5.6%) had an anastomotic leak, without need for operative intervention and another patient developed an anastomotic stricture, resolved with a single endoscopic dilation. Chylothorax occurred in three patients; two of these required a surgical intervention. Pulmonary complications occurred in six patients (16.7%). Based on Comprehensive Complications Index (CCI), median values of complications were 27.9 (ranging from 20.9 to 100). The results of our study suggest that TMIIL with a 3-cm linear-stapled anastomosis seems to be safe and effective, with low rates of post-operative anastomotic leak and stricture.

From McKeown to Ivor Lewis, the learning curve for thoracic lymphadenectomy over the first 100 robotic esophagectomy cases: a retrospective study

Background

Lymphadenectomy is an essential but challenging part of the surgical treatment for esophageal cancer. However, the previously reported learning curve for robotic esophagectomy primarily focused on only one surgical approach (McKeown or Ivor Lewis). However, both approaches must be mastered by a mature robotic surgical team to deal with different clinical conditions and satisfy patients' needs. This study aimed to show how an experienced esophageal surgical team became proficient in both McKeown and Ivor Lewis robotic esophagectomy.

Methods

A retrospective review of the first 100 cases of robot-assisted minimally invasive esophagectomy (RAMIE) by a single surgical team was performed. The cumulative sum (CUSUM) analysis was used to distinguish the change point during the learning course. A subgroup analysis was performed according to a surgical approach (McKeown or Ivor Lewis) to determine the effect of experience from one surgical approach on learning the other RAMIE technique.

Results

According to the tendency of the CUSUM plot, the learning curve was divided into four phases. The subgroup analysis indicated the decline of the CUSUM plot in the 3rd phase originated from the start of the Ivor Lewis approach. The attending surgeon took 23 cases to achieve a significant improvement in the number of harvested thoracic lymph nodes using the McKeown approach. Regardless of the acquired experience of McKeown RAMIE, it took another 18 cases for the surgical team to achieve significant improvement in harvesting thoracic lymph nodes using the Ivor Lewis approach.

Conclusions

Twenty-three cases were needed for an experienced surgical team to improve thoracic lymphadenectomy results using McKeown RAMIE. There was another learning phase during the transition from McKeown to Ivor Lewis esophagectomy. Importantly, the acquired experience from performing McKeown RAMIE could shorten how long it takes to learn Ivor Lewis RAMIE.

Differences in the Exposure of the Lumbar Nerve Root Between Experts and Novices: Results From a Realistic Simulation Pilot Study With Force Sensors

STUDY DESIGN

Nonrandomized prospective trial.

OBJECTIVE

Several studies could demonstrate "learning curves" in almost every single surgical procedure for unexperienced surgeons. This is in sharp contrast to the rising quality requirements in public health care to provide surgical training at patients "expense." The aim of this study was to visualize, measure, and set a baseline of the pressure load on the spinal nerve root during a simulated microdiscectomy on a standardized and validated model (RealSpine) under the influence of the level of surgical experience and individual skills.

METHODS

Five highly experienced spine surgeons and 5 trainees without considerable surgical experience were selected to perform a standardized microsurgical discectomy on a validated RealSpine simulator. Force-torque sensors were integrated in this simulator to measure the load on the nerve root. The forces were recorded every 125 ms.

RESULTS

We could identify cumulative for the total intervention as well as for defined single surgical steps of this procedure and as well in between the single subjects a significant higher tension and contusion forces on the nerve for the trainee group (Δp contusion 83-765 Nċs and Δp tension 159-1131 Nċs for the trainees. Δp contusion 16-171 Nċs and Δp tension 27-146 Nċs for the experts).

CONCLUSION

We could measure a difference between unexperienced and experienced surgeons regarding the manipulations of the nerve root during a standardized simulated microdiscectomy. This possibility could be the starting point for a new and innovative surgical education to improve outcome without negative side effects of "learning curves."

Supraclavicular Approach for Neurogenic Thoracic Outlet Syndrome: Description of a Learning Curve

BACKGROUND

The supraclavicular exposure represents an alternative approach for thoracic outlet decompression in neurogenic thoracic outlet syndrome with unique access to neurovascular structures. We aimed to evaluate the learning curve for this approach and associated patient outcomes.

METHODS

Patients undergoing first-time, unilateral, supraclavicular thoracic outlet decompression for neurogenic thoracic outlet syndrome were included. Cumulative-sum and linear-spline-regression analyses were used to determine the operative time learning curve. Patients were consecutively organized into early (learning phase) and late (competency) cohorts. Primary endpoints were the operative time learning curve operation number and association of this learning curve on differences in self-reported postoperative symptomatic improvement between early and late cohorts, adjusting for American Society of Anesthesiology classification, body mass index, previous treatment (opioid/neuropathic medication/botulinum-injection), and length of stay.

RESULTS

Among 114 patients, learning curve analyses showed decreasing operative times, plateauing at the 51st operation (ß = -1.63, 95% confidence interval [-2.30, -0.95], P < .001). No periprocedural differences existed between early (operations 1-50) and late (operations 51-114) cohorts. Self-reported 90-day outcomes were similar in early and late cohorts (odds ratio [OR]: 1.60 [0.65, 3.95], P = .31). Mediators of poor self-reported outcomes included increasing American Society of Anesthesiology classification (OR 0.21 [0.08, 0.54], P = .001), failed preoperative botulinum injection (OR 0.15 [0.03, 0.65], P = .01), and increased length of stay (OR 0.40 [0.22, 0.73], P = .003).

CONCLUSIONS

The learning curve for supraclavicular thoracic outlet decompression in neurogenic thoracic outlet syndrome occurred after 51 operations with a trend towards improved 90-day self-reported outcomes from the early to late phases. These findings, along with mediators of poorer outcomes, may aid surgeons in adopting a new approach and counseling patients on expected outcomes.

Robot-assisted minimally invasive esophagectomy (RAMIE): tips and tricks from the bedside assistant view-expert experiences

The role of bedside assistants in robot-assisted minimally invasive esophagectomy is important. It includes knowledge of the procedure, knowledge of the da Vinci Surgical System, skills in laparoscopy, and good communicative skills. An experienced bedside assistant will likely improve efficiency and safety of robot-assisted minimally invasive esophagectomy.

A structured training pathway to implement robot-assisted minimally invasive esophagectomy: the learning curve results from a high-volume center

To ensure safe implementation of robot-assisted minimally invasive esophagectomy (RAMIE), the learning process should be optimized. This study aimed to report the results of a surgeon who implemented RAMIE in a German high-volume center by following a tailored and structured training pathway that involved proctoring. Consecutive patients who underwent RAMIE during the course of the program were included from a prospective database. A single surgeon, who had prior experience in conventional MIE, performed all RAMIE procedures. Cumulative sum (CUSUM) learning curves were plotted for the thoracic operating time and intraoperative blood loss. Perioperative outcomes were compared between patients who underwent surgery before and after a learning curve plateau occurred. Between 2017 and 2018, the adopting center adhered to the structured training pathway, and a total of 70 patients were included in the analysis. The CUSUM learning curves showed plateaus after 22 cases. In consecutive cases 23 to 70, the operating time was shorter for both the thoracic phase (median 215 vs. 249 minutes, P = 0.001) and overall procedure (median 394 vs. 440 minutes, P = 0.005), intraoperative blood loss was less (median 210 vs. 400 milliliters, P = 0.029), and lymph node yield was higher (median 32 vs. 23 nodes, P = 0.001) when compared to cases 1 to 22. No significant differences were found in terms of conversion rates, postoperative complications, length of stay, completeness of resection, or mortality. In conclusion, the structured training pathway resulted in a short and safe learning curve for RAMIE in this single center's experience. As the pathway seems effective in implementing RAMIE without compromising the early oncological outcomes and complication rates, it is advised for surgeons who are wanting to adopt this technique.

Prospective validation of classification of intraoperative adverse events (ClassIntra): international, multicentre cohort study

OBJECTIVE

To prospectively assess the construct and criterion validity of ClassIntra version 1.0, a newly developed classification for assessing intraoperative adverse events.

DESIGN

International, multicentre cohort study.

SETTING

18 secondary and tertiary centres from 12 countries in Europe, Oceania, and North America.

PARTICIPANTS

The cohort study included a representative sample of 2520 patients in hospital having any type of surgery, followed up until discharge. A follow-up to assess mortality at 30 days was performed in 2372 patients (94%). A survey was sent to a representative sample of 163 surgeons and anaesthetists from participating centres.

MAIN OUTCOME MEASURES

Intraoperative complications were assessed according to ClassIntra. Postoperative complications were assessed daily until discharge from hospital with the Clavien-Dindo classification. The primary endpoint was construct validity by investigating the risk adjusted association between the most severe intraoperative and postoperative complications, measured in a multivariable hierarchical proportional odds model. For criterion validity, inter-rater reliability was evaluated in a survey of 10 fictitious case scenarios describing intraoperative complications.

RESULTS

Of 2520 patients enrolled, 610 (24%) experienced at least one intraoperative adverse event and 838 (33%) at least one postoperative complication. Multivariable analysis showed a gradual increase in risk for a more severe postoperative complication with increasing grade of ClassIntra: ClassIntra grade I versus grade 0, odds ratio 0.99 (95% confidence interval 0.69 to 1.42); grade II versus grade 0, 1.39 (0.97 to 2.00); grade III versus grade 0, 2.62 (1.31 to 5.26); and grade IV versus grade 0, 3.81 (1.19 to 12.2). ClassIntra showed high criterion validity with an intraclass correlation coefficient of 0.76 (95% confidence interval 0.59 to 0.91) in the survey (response rate 83%).

CONCLUSIONS

ClassIntra is the first prospectively validated classification for assessing intraoperative adverse events in a standardised way, linking them to postoperative complications with the well established Clavien-Dindo classification. ClassIntra can be incorporated into routine practice in perioperative surgical safety checklists, or used as a monitoring and outcome reporting tool for different surgical disciplines. Future studies should investigate whether the tool is useful to stratify patients to the appropriate postoperative care, to enhance the quality of surgical interventions, and to improve long term outcomes of surgical patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03009929.

Safety and Performance of Bone-Anchored Prostheses in Persons with a Transfemoral Amputation: A 5-Year Follow-up Study

BACKGROUND

For almost 30 years, bone-anchored prostheses have offered an alternative solution to prosthetic sockets by attaching the artificial limb directly to the femoral residuum by means of an osseointegration implant. Osseointegration implant surgery was introduced in our center in 2009. The aim of the present study is to report on safety, prosthesis-wearing time, and health-related quality-of-life (HRQoL) for patients with femoral bone-anchored prostheses during a 5-year follow-up period.

METHODS

All patients who underwent implantation of a press-fit osseointegration implant between May 2009 and November 2013 were eligible for the present study. Implantation was performed in 2 stages. Adverse events included infectious complications (grade 1 to 4), aseptic loosening, breakage, stoma-redundant tissue, and stoma hypergranulation. Prosthesis-wearing time and HRQoL were measured with the Questionnaire for Persons with a Transfemoral Amputation (Q-TFA) prosthetic use score and global score, respectively.

RESULTS

Thirty-nine of 42 eligible patients were included. Thirty patients (77%) presented with some kind of infection (156 events in total), with 148 (95%) events being classified as grade 1 or 2 and 8 events (5%) being classified as grade 3; the latter 8 events occurred in 4 patients. There were no instances of septic loosening. The intramedullary stem of the osseointegration implant broke in 2 patients. In total, soft-tissue refashioning had to be done 30 times in 14 patients. The Q-TFA median prosthetic use and global scores improved significantly from 71 to 100 and from 33 to 75, respectively (p < 0.001).

CONCLUSIONS

Despite the adverse events, patient prosthetic use and HRQoL improved significantly. Grade-1 and 2 infections were frequent but could mostly be treated with nonoperative measures. Most infections seemed to occur in the first 2 years and did not lead to deep infections. Two broken intramedullary stems were revised successfully. Current developments focus on reduction of infectious complications and prevention of osseointegration implant breakage.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Conversion to open surgery during minimally invasive esophagectomy portends worse short-term outcomes: an analysis of the National Cancer Database

OBJECTIVE

The objectives were to determine factors associated with conversion to open surgery in patients with esophageal cancer who underwent minimally invasive esophagectomy (MIE, including laparo-thoracoscopic and robotic) and the impact of conversion to open surgery on patient outcomes.

METHODS

We included patients from the National Cancer Database with esophageal and gastroesophageal junction cancer who underwent MIE from 2010 to 2015. Patient-, tumor-, and facility-related characteristics as well as short-term and oncologic outcomes were compared between patients who were converted to open surgery and those who underwent successful MIE without conversion to open surgery. Multivariable logistic regression models were used to analyze risk factors for conversion to open surgery from attempted MIE.

RESULTS

7306 patients underwent attempted MIE. Of these patients, 82 of 1487 (5.2%) robotic-assisted esophagectomies were converted to open, compared to 691 of 5737 (12.0%) laparo-thoracoscopic esophagectomies (p < 0.001). Conversion rates decreased significantly over the study period (ptrend = 0.010). Patient age, tumor size, and nodal involvement were independently associated with conversion. Facility minimally invasive cumulative volume and robotic approach were associated with decreased conversion rates. Patients whose MIEs were converted had increased 90-day mortality [Odds Ratio (OR) 1.49; 95% Confidence Interval (CI) 1.10, 2.02], prolonged hospital stay (OR 1.39; 95% CI 1.17, 1.66), and higher rates of unplanned readmission (OR 1.67; 95% CI 1.27, 2.20). No significant differences were found in surgical margins or number of lymph nodes harvested.

CONCLUSION

Patients undergoing attempted MIE requiring conversion to open surgery had significantly worse short-term outcomes including postoperative mortality. Patient factors and hospital experience contribute to conversion rates. These findings should inform surgeons and patients considering esophagectomy for cancer.

Transition from open to minimally invasive en bloc esophagectomy can be achieved without compromising surgical quality

BACKGROUND

En bloc esophagectomy results in higher lymph node (LN) retrieval than standard esophagectomy. Minimally invasive esophagectomy (MIE) has gained traction due to improved short-term outcomes, but many large series report LN yields well below the international benchmark of 23. We sought to determine if an established approach to open en bloc resection can be safely transferred to MIE using LN yield as a quality benchmark.

METHODS

An open approach to en bloc esophagectomy (OE) was established over 5 years (~ 300 cases) before en bloc MIE was introduced in 2010. Patients undergoing curative-intent en bloc Ivor-Lewis and McKeown esophagectomy for cancer from 2010 to 2019 by a single surgeon with formal minimally invasive surgery training were identified from a prospectively collected database. Mann-Whitney U and χ² tests and cumulative sum analysis were used for statistical analysis. "Failure" was defined as LN yield less than AJCC's 8th edition guidelines: 10 LNs for pT1 cancers, 20 for pT2 and 30 for pT3-4.

RESULTS

A total of 269 esophageal resections met inclusion criteria [193(72%) OE; 76(28%) MIE]. Age, sex, BMI and comorbidities were comparable between groups. Tumors were larger and more often locally advanced in OE. Median LN retrieval was sufficient by international standards in both groups [OE:34(27-46); MIE:28(22-39); p = 0.01]. "Failures" occurred in 33(17%) of OE and 12(16%) MIE cases (p = 0.63). No learning effect was observed for LN yield. R0 resection rate was comparable [OE:191(99%); MIE:73(96%); p = 0.90]. Operative time was longer for MIE [275(246-300)] than OE [240(210-270) minutes], p < 0.0001, while estimated blood loss (OE:350(250-500)mL; MIE:300(200-400)mL; p = 0.02] and length of stay [OE:8(6-13); MIE7(6-9) days; p = 0.02] were higher for OE. Morbidity and mortality were comparable between groups and LN yield did not impact survival.

CONCLUSIONS

Under appropriate conditions, an established approach to open en bloc esophagectomy can be safely transferred to MIE without compromising surgical quality.

Totally minimally invasive esophagectomy versus hybrid minimally invasive esophagectomy: systematic review and meta-analysis

Minimally invasive esophagectomy is increasingly performed for the treatment of esophageal cancer, but it is unclear whether hybrid minimally invasive esophagectomy (HMIE) or totally minimally invasive esophagectomy (TMIE) should be preferred. The objective of this study was to perform a meta-analysis of studies comparing HMIE with TMIE. A systematic literature search was performed in MEDLINE, Embase, and the Cochrane Library. Articles comparing HMIE and TMIE were included. The Newcastle-Ottawa scale was used for critical appraisal of methodological quality. The primary outcome was pneumonia. Sensitivity analysis was performed by analyzing outcome for open chest hybrid MIE versus total TMIE and open abdomen MIE versus TMIE separately. Therefore, subgroup analysis was performed for laparoscopy-assisted HMIE versus TMIE, thoracoscopy-assisted HMIE versus TMIE, Ivor Lewis HMIE versus Ivor Lewis TMIE, and McKeown HMIE versus McKeown TMIE. There were no randomized controlled trials. Twenty-nine studies with a total of 3732 patients were included. Studies had a low to moderate risk of bias. In the main analysis, the pooled incidence of pneumonia was 19.0% after HMIE and 9.8% after TMIE which was not significantly different between the groups (RR: 1.46, 95% CI: 0.97-2.20). TMIE was associated with a lower incidence of wound infections (RR: 1.81, 95% CI: 1.13-2.90) and less blood loss (SMD: 0.78, 95% CI: 0.34-1.22) but with longer operative time (SMD:-0.33, 95% CI: -0.59--0.08). In subgroup analysis, laparoscopy-assisted HMIE was associated with a higher lymph node count than TMIE, and Ivor Lewis HMIE was associated with a lower anastomotic leakage rate than Ivor Lewis TMIE. In general, TMIE was associated with moderately lower morbidity compared to HMIE, but randomized controlled evidence is lacking. The higher leakage rate and lower lymph node count that was found after TMIE in sensitivity analysis indicate that TMIE can also have disadvantages. The findings of this meta-analysis should be considered carefully by surgeons when moving from HMIE to TMIE.

Robot assisted versus laparoscopic suturing learning curve in a simulated setting

Background

Compared to conventional laparoscopy, robot assisted surgery is expected to have most potential in difficult areas and demanding technical skills like minimally invasive suturing. This study was performed to identify the differences in the learning curves of laparoscopic versus robot assisted suturing.

Method

Novice participants performed three suturing tasks on the EoSim laparoscopic augmented reality simulator or the RobotiX robot assisted virtual reality simulator. Each participant performed an intracorporeal suturing task, a tilted plane needle transfer task and an anastomosis needle transfer task. To complete the learning curve, all tasks were repeated up to twenty repetitions or until a time plateau was reached. Clinically relevant and comparable parameters regarding time, movements and safety were recorded. Intracorporeal suturing time and cumulative sum analysis was used to compare the learning curves and phases.

Results

Seventeen participants completed the learning curve laparoscopically and 30 robot assisted. Median first knot suturing time was 611 s (s) for laparoscopic versus 251 s for robot assisted (p < 0.001), and this was 324 s versus 165 (sixth knot, p < 0.001) and 257 s and 149 s (eleventh knot, p < 0.001) respectively on base of the found learning phases. The percentage of ‘adequate surgical knots’ was higher in the laparoscopic than in the robot assisted group. First knot: 71% versus 60%, sixth knot: 100% versus 83%, and eleventh knot: 100% versus 73%. When assessing the ‘instrument out of view’ parameter, the robot assisted group scored a median of 0% after repetition four. In the laparoscopic group, the instrument out of view increased from 3.1 to 3.9% (left) and from 3.0 to 4.1% (right) between the first and eleventh knot (p > 0.05).

Conclusion

The learning curve of minimally invasive suturing shows a shorter task time curve using robotic assistance compared to the laparoscopic curve. However, laparoscopic outcomes show good end results with rapid outcome improvement.

Electronic supplementary material

The online version of this article (10.1007/s00464-019-07263-2) contains supplementary material, which is available to authorized users.